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Vol. VI, No. 08~ EINet News Briefs ~ May 9 , 2003

****A free service of the APEC Emerging Infections Network*****

The EINet listserv was created to foster discussion, networking, and collaboration in the area of emerging infectious diseases (EID's) among academicians, scientists, and policy makers in the Asia–Pacific region. We strongly encourage you to share their perspectives and experiences, as your participation directly contributes to the richness of the "electronic discussions" that occur. To respond to the listserv, use the reply function.

In this edition:
  1. Infectious disease information
    – Vietnam: Suspected Enterovirus, Childhood Deaths toll doubles to reach 38
    – Cambodia (Northeast): Undiagnosed respiratory disease
    – Russia (Urals): Flare of Diphtheria Closes School for Quarantine in Nizhny Tagil
    – WHO: Harm reduction is safe and effective
    – Canada: Suspected human Anthrax on shipboard
    – Canada (Ontario): Infection of the West Nile Virus–positive Crow
    – Chile: Dengue Mosquito found for the first time
    – Netherlands, Belgium: Avian influenza and vaccination
    – EU: extends US poultry ban due to Newcastle disease
  2. Updates
    – Multi Country Outbreak: Severe Acute Respiratory Syndrome (SARS)
    China (Liaoling): Investigation Results of Milk Poisoning Case
  3. Notices
    Obituary: Dr Carlo Urbani
    – Training: 2nd Leadership Training on Gender, Sexuality and Sexual Health Center for Health Policy Studies in Bangkok, Thailand from Aug. 18 to Sept. 5, 2003
  4. Articles
    Clinical Features and Short–term Outcomes of 144 Patients with SARS in the
    Greater Toronto Area.
    Comparative full–length genome sequence analysis of 14 SARS coronavirus isolates and common mutations associated with putative origins of infection
    Comparative analysis of the SARS coronavirus genome: a good start to a long journey
    Clinical progression and viral load in a community outbreak of coronavirus–associated SARS pneumonia: a prospective study
    Risk of prevalent HIV infection associated with incarceration among injecting
    drug users in Bangkok, Thailand: case–control study.
  5. How to join the EINet email list

Below is a semi–monthly summary of Asia–Pacific emerging infectious diseases.


Vietnam – Suspected Enterovirus, Childhood Deaths toll doubles to reach 38
According to state–controlled media, an unidentified sickness has killed 38 children and left more than 60 others ill in 17 Vietnamese provinces in the past 3 months. The disease is suspected to be caused by enterovirus and is believed to attack the intestines and the brain. Officials said it did not appear to be Human enterovirus 71, which killed 30 children in Malaysia in 1997 and more than 50 children in Taiwan in 1998 and is currently responsible for an extensive outbreak in Sarawak.

Doctors and medical experts, along with the WHO, completed an epidemiology survey in Ho Chi Minh City on Apr. 15, 2003. They did not classify the illness as an outbreak because the cases did not appear to be linked and were scattered throughout many provinces, the newspaper said. All the children who died of the disease experienced high fever and convulsion. Nearly 70 per cent of them died within a day of becoming sick.

Mr. Nguyen Van Thuong, Vice–Minister of Health, told health institutes to work closely to carry out a more thorough study of the disease and to work out a uniform diagnosis and treatment method for all hospitals.
(ProMed 4/27/03)

Cambodia (Northeast) — Undiagnosed respiratory disease
The unknown disease has killed 7 of the 392 people infected in the villages of Borghok and Ping in northeastern Cambodia. After weeks of investigations, Western and Cambodian doctors have ruled out severe acute respiratory syndrome. The symptoms included fever, coughing, breathing problems — all signs of SARS. But the victims also suffered from diarrhea and maintained normal white blood cell counts, something not usually found in SARS patients.

"There is no evidence that this outbreak is in any way linked to SARS," said the joint mission's report. But the bad news is doctors still don't know much more about the disease. "A spate of deaths like this caused by an illness we cannot determine by tests is unusual," said Dr. Severin Xylander, a German doctor and the only World Health Organization representative to visit the area.

The village chief, doesn't care. He says he brought the disease under control with rituals he conducted on Mar. 20, 2003, witnessed by about 200 villagers. "It stopped tormenting us after the big ceremony. I know, because people stopped dying and didn't get sick anymore," he said.
(ProMed 5/08/03)

Russia (Urals) — Flare of Diphtheria Closes School for Quarantine in Nizhny Tagil
Free vaccines against diphtheria are now being administered to children in the Russian city of Nizhny Tagil in the Urals, after an outbreak of the disease hospitalized 20 children and a teacher and closed the school they attended.

All of the affected children had been vaccinated, leading Yelena Romashina, chief doctor of the city's sanitary and epidemic monitoring service, to suggest that it might be a new form of the disease resistant to the existing vaccine. Cases of diphtheria have also been recorded in other area schools and nurseries, as well as among some of the patients' family members.
(ProMed 5/02/03)

WHO — Harm reduction is safe and effective
The controversial harm reduction approach such as the needle and syringe program, whose introduction has met with strong opposition abroad, is gradually gaining ground in several countries as a true complement for two previous drug eradication approaches: demand reduction and supply reduction.

Tom Moore of the World Health Organization (WHO) said that the harm reduction approach had gained support in several countries because, contrary to popular belief, this program was not only safe, but also effective and cost–effective in addressing the HIV/AIDS epidemic.

"By 2000, the needle and syringe program in 103 cities across Australia had prevented 25,000 HIV infections and 21,000 HCV (Hepatitis C) infections. By 2010, it will have prevented 5,000 HIV–related deaths," and "An international review has reported the decrease of HIV prevalence by 5.8 percent in 29 cities with the program, and an increase of HIV prevalence by 5.9 percent in 52 cities without the program," he said.

The harm reduction approach has been implemented in various degrees in areas throughout Europe, Latin America, India, Southeast Asia and Australia.
(SEA–AIDS 4/23/03)


Canada — Suspected human Anthrax on shipboard
A cargo ship bound for a Quebec port will be intercepted by Canadian authorities, after it was learned that an officer on board died of the bacterial disease anthrax this week.

The Wadi Al Arab, an Egyptian vessel carrying about 50,000 tons of bauxite to an Alcan aluminum plant in Saguenay, will be diverted to Halifax and inspected by Health Canada, Transport Canada, and the Royal Canadian Mounted Police for possible anthrax contamination.

An Alcan spokesperson alerted health officials after being told by the crew that the first mate had died from anthrax and had been left behind in Brazil. By midnight April 26, the ship was over 300 nautical miles outside Canadian waters, about a day's journey away. It will not be allowed into any other port until shown to be disease–free.
(ProMed 4/27/03)

Canada (Ontario) — Infection of the West Nile Virus–positive Crow
According to Canadian Cooperative Wildlife Health Centre, the infected bird was detected dead on Apr. 15, 2003, picked up by public health authorities on Apr. 17, and stored under unknown conditions and submitted for diagnosis on Apr. 24. On Apr. 25, 2003 it was reported positive for West Nile Virus by VecTest using the eluate of an oropharyngeal swab, confirmed the same day using PCR on combined samples of brain and kidney tissue. In addition, the fact that evidence of West Nile virus over–wintering in Culex pipiens mosquitoes has been documented in southern Ontario (Drebot et al. 2003), it is considered quite possible that the Newmarket crow was infected via a mosquito bite.
(ProMed 5/04/03, 5/02/03, 4/28/03)

Chile — Dengue Mosquito found for the first time
The Aedes aegypti, the mosquito responsible for the spread of dengue and yellow fever, has been detected again in the continental area of Chile a century after its eradication. The Chilean national surveillance program detected one female specimen of the feared mosquito Aedes aegypti in the Huasco province, located in the northern part of the country.

"This is the first observation of the insect in the area since its eradication at the beginning of the twentieth century," said Cecilia Perret, director of the tropical diseases laboratory at the Catholic
University. She added that Chile had been the only country in South and Central America free of the presence of the Aedes aegypti.

The National Office of Emergencies is distributing water in the Huasco Province, which is known for its dryness. Due to the scarcity of water, the villagers usually store water in containers that can facilitate the reproduction of the mosquito. Mosquitoes typically breed in standing water, including rain water that collects in old tires or containers.
(ProMed 4/17/03)


Netherlands, Belgium — Avian influenza and Vaccination
Outbreaks of a highly pathogenic strain of avian influenza virus A (H7N7) have been reported in various poultry farms in the Netherlands since February 2003. Recent cases of the disease in poultry also have been reported in Belgium. While avian influenza strains normally exclusively infect poultry, Dutch authorities have reported that the H7N7 strain has now jumped the species barrier, causing one death and more than 80 cases of mild disease in humans. A 57–year–old veterinarian who visited a poultry farm affected by the (H7N7) strain died on April 17 of acute respiratory distress syndrome in the Netherlands. H7N7 influenza virus was isolated from the patient.

The WHO Global Influenza Surveillance Network is currently assembling a test kit for H7N7 that will be ready for use in three weeks. As a precautionary measure, the network is also working on the development of a vaccine for H7N7.

The European Commission has agreed recently to the vaccination of avian influenza (or AI) –susceptible birds in zoos. Based upon the Ministerial Decree, such vaccinations are allowed, provided some conditions are fulfilled: data on the vaccinated birds should be maintained for 10 years following the vaccination; results of their serological tests should be kept for 10 years; movement to other zoos is allowed only if officially supervised; and no products derived from such birds are allowed in the food chain.

Reports concerning avian influenza from the Standing Committee on the Food Chain and Animal Health and COMMISION DECISION of European Union concerning protection measures in relation to avian influenza in Belgian are available at the following site: http://www.favv.be/indexEN.htm
(WHO–WER 4/24/03, ProMed 4/19/03, 5/02/03)

EU— extends US poultry ban due to Newcastle disease
According to the EU executive, the European Union (EU) has extended its ban on poultry imports from the United States as the highly contagious Newcastle disease (NCD) spreads across more US state borders.

All live poultry imports including hatching eggs, fresh poultry meat, and poultry products were now stopped from El Paso and Hudspeth counties in the US state of Texas and the counties of Dona Ana, Luna, and Otero in neighboring New Mexico.

The confirmation of an outbreak of the virus in Texas on Apr. 11, 2003 had prompted the 15–nation block to extend its ban, the European Commission said. At the end of January 2003 the EU blocked poultry imports from California, Nevada, and Arizona after outbreaks of the disease in those states. The extended ban will now apply until Aug. 1, 2003.

NCD can wipe out poultry populations and affects the birds' respiratory, nervous, and digestive systems. It spreads primarily through direct contact between healthy birds and the bodily discharges of infected birds. The virus is fatal for fowl but harmless to humans. The last US outbreak was in 1971.
(ProMed 4/27/03)


Multi Country Outbreak — Severe Acute Respiratory Syndrome (SARS)
On May 7, 2003, the World Health Organization (WHO) has revised its initial estimates of the case fatality ratio of SARS based on an analysis of the latest data from Canada, China, Hong Kong SAR, Singapore, and Viet Nam. The overall estimate of case fatality is 14% to 15%, ranging 0% to 50% depending on the affected age group.

WHO has also reviewed estimates of the incubation period SARS and then they conclude that the current best estimate of the maximum incubation period is 10 days. WHO continues to recommend the earliest possible isolation of all suspected and probable cases of SARS.

According to new laboratory studies, the SARS virus can survive on common surfaces at room temperature for hours or even days. “This shows that transmission by contaminated hands or contaminated objects in the environment can play a role,” said Klaus Stohr, the WHO’s top scientist. He also said, “What we don’t know is the infectious dose.”

As of May 7, 2003, a cumulative total of 6,903 SARS cases, 495 deaths, and 2885 recovered cases since November 1, 2002, are reported from the following countries (number of cases): Australia (4), Brazil (2), Canada (146), China (4560), Hong Kong Special Administrative Region of China (1654), Macao Special Administrative Region of China (1), Chinese Taipei (27), Colombia (1), France (6), Germany (8), Italy (1), Kuwait (1), Malaysia (7), Mongolia (9), Philippines (10), Republic of Ireland (1), Republic of Korea (1), Romania (1), Singapore (204), South Africa (1), Spain (1), Sweden (3), Switzerland (1), Thailand (7), United Kingdom (6), United States (65), Viet Nam (63).

In order to see further details, including cumulative number of cases and deaths, please visit the following URL:

As of May 7, 2003, WHO has listed the following areas with recent local transmission of SARS, where in the last 20 days, one or more reported cases of SARS have most likely acquired their infection locally regardless of the setting in which this may be occurred: China (Beijing, Guangdong Province, Hong Kong SAR, Inner Mongolia, Shanxi Province, Tianjin, and Taiwan Province), Canada (Toronto), Mongolia, Philippines, and Singapore. http://www.who.int/csr/sarsareas/2003_05_07/en/

For the full WHO travel advisory, together with additional information about this disease, please visit the following URL: http://www.who.int/csr/sars/en/

For information from CDC including guidelines and recommendations, please visit the following URL:

For information from Department of Health Hong Kong SAR, please visit the following URL:

– A panel of WHO staff had a video conference with Hong Kong government officials on May 6, Dr. Heymann, Executive Director for Communicable Diseases, called the efforts taken in Hong Kong to stem the spread of SARS as “heroic” and added “All of us have nothing but admiration for you and your team”. (To see more details, visit the following site: http://www.who.int/csr/don/2003_05_06/en/ )

For information from Singapore Ministry of Health, please visit the following URL:
(WHO Disease Outbreak News 5/07/03, ProMed 5/04/03)

China (Liaoling) — Investigation Results of Milk Poisoning Case
On Mar. 19, 2003, about 4900 students from 8 elementary schools in Haicheng drank a certain kind of soy milk and 2556 of them became sick afterward.

The experts determined that some kind of trypsin inhibitor in the soy milk was the cause of the accident, and people allergic to the agent would suffer digestive tract problems after consuming the soy milk. They also ruled out the possibility of bacterial, chemical, and animal poisons.
Experts also held that people usually recover well from the sickness and there will be no long–term, potential harm to the body.

As of the evening of Apr. 15, 2003, 84 pupils had been under treatment in 3 local hospitals. (ProMed 4/20/03)
Obituary: Dr Carlo Urbani

Dr. Carlo Urabani, a dedicated and internationally respected Italian epidemiologist, he died at age of 46 in Bangkok from SARS, the new disease that he had helped to identify.

“His wife Giuliana told me that a few days before falling ill he had argued with her. She was concerned to see him working with patients with such a deadly disease. He said: "If I cannot work in such situations, what am I here for — answering emails, going to cocktail parties, and pushing paper?"

He is survived by his wife, sons Tommaso and Luca, and daughter Maddalena.”

To see the entire obituary, please visit the following site:
(Guradina Unlimited (www.guradian.co.uk), ProMed 4/22/03)

Second Leadership Training on Gender, Sexuality and Sexual Health Center for Health Policy Studies (Bangkok, Thailand from August 18 to September 5, 2003)
The Southeast Asian Research Consortium on Gender, Sexuality and Sexual Health, with the Secretariat at the University of the Philippines and primary support from the Rockefeller Foundation, will hold the Second Leadership Training on Sexuality and Gender, at Mahidol University in Bangkok, Thailand from August 18 to September 5, 2003.

The course is designed for people working with government and non–government organizations on sexual and reproductive health. This regional course aims to provide the participants with context–specific and gender–sensitive knowledge on sexuality and sexual health in Southeast Asia and China, while exploring relevant theoretical and methodological issues.

Special attention will be devoted to exploring how conceptual and theoretical frameworks, especially gender and socio–cultural theories, can be applied to policy and interventions to enhance sexual and reproductive health in the region.

Lecturers will include Dr. Pimpawun Boonmongkorn, Dr. Philip Guest, Prof. Irwan Hidayana, Dr. Le Minh Giang, Dr. Darwin Muhadjir and Dr. Michael Tan.

For more information, contact the secretariat at:

Center for Health Policy Studies
Faculty of Social Science and Humanities
Mahidol University,
Puttamonthon 4 Road
Salaya, Nakornpathom
73170, Thailand

Tel: 662𤮩�, 662𤮩�
Fax: 662𤮩�, 662𤮩�
Email: coordinator@sexualitycourse.com
Website: http://www.sexualitycourse.com
(SEA–AIDS 5/03/03)


Clinical Features and Short–term Outcomes of 144 Patients with SARS in the
Greater Toronto Area

(http://jama.ama–assn.org/cgi/content/full/289.21.JOC30885v1 )

CONTEXT: Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide.

OBJECTIVES: To describe the clinical characteristics and short–term outcomes of SARS in the first large group of patients in North America; to describe how these patients were treated and the variables associated with poor outcome.

DESIGN, SETTING, and PATIENTS: Retrospective case series involving 144 adult patients admitted to 10 academic and community hospitals in the greater Toronto, Ontario, area between March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS. Patients were included if they had fever, a known exposure to SARS, and respiratory symptoms or infiltrates observed on chest radiograph. Patients were excluded if an alternative diagnosis was determined.

MAIN OUTCOME MEASURES: Location of exposure to SARS; features of the history, physical examination, and laboratory tests at admission to the hospital; and 21–day outcomes such as death or intensive care unit (ICU) admission with or without mechanical ventilation.

RESULTS: Of the 144 patients, 111 (77%) were exposed to SARS in the hospital setting. Features of the clinical examination most commonly found in these patients at admission were self–reported fever (99%), documented elevated temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%). Common laboratory features included elevated lactate dehydrogenase (87%), hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea. A total of 126 patients (88%) were treated with ribavirin, although its use was associated with significant toxicity, including hemolysis (in 76%) and decrease in hemoglobin of 2 g/dL (in 49%). Twenty–nine patients (20%) were admitted to the ICU with or without mechanical ventilation, and 8 patients died (21–day mortality, 6.5%; 95% confidence interval [CI], 1.9%㪣.8%). Multivariable analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95% CI, 1.4ף.2; P =.01) or other comorbid conditions (RR, 2.5; 95% CI, 1.1ס.8; P =.03) were independently associated with poor outcome (death, ICU admission, or mechanical ventilation).

CONCLUSIONS: The majority of cases in the SARS outbreak in the greater Toronto area were related to hospital exposure. In the event that contact history becomes unreliable, several features of the clinical presentation will be useful in raising the suspicion of SARS. Although SARS is
associated with significant morbidity and mortality, especially in patients with diabetes or other comorbid conditions, the vast majority (93.5%) of patients in our cohort survived.”
(Booth CM, et al.JAMA. 2003 May 6)

Comparative full–length genome sequence analysis of 14 SARS coronavirus isolates and common mutations associated with putative origins of infection
(http://image.thelancet.com/extras/03art4454web.pdf )

Background: The cause of severe acute respiratory syndrome (SARS) has been identified as a new coronavirus. Whole genome sequence analysis of various isolates might provide an indication of potential strain differences of this new virus. Moreover, mutation analysis will help to develop effective vaccines.

Methods: We sequenced the entire SARS viral genome of cultured isolates from the index case (SIN2500) presenting in Singapore, from three primary contacts (SIN2774, SIN2748, and SIN2677), and one secondary contact (SIN2679). These sequences were compared with the isolates from Canada (TOR2), Hong Kong (CUHK–W1, and HKU39849), Hanoi (URBANI), Guangzhou (GZ01), and Beijing (BJ01, BJ02, BJ03, BJ04).

Findings: We identified 129 sequence variations among the 14 isolates, with 16 recurrent variant sequences. Common variant sequences at four loci define two distinct genotypes of the SARS virus. One genotype was linked with infections originating in Hotel M in Hong Kong, the second contained isolates from Hong Kong, Guangzhou, and Beijing with no association with Hotel M (p<0•0001). Moreover, other common sequence variants further distinguished the geographical origins of the isolates, especially between Singapore and Beijing.

Interpretation: Despite the recent onset of the SARS epidemic, genetic signatures are emerging that partition the worldwide SARS viral isolates into groups on the basis of contact source history and geography. These signatures can be used to trace sources of infection. In addition, a common variant associated with a non–conservative aminoacid change in the S1 region of the spike protein, suggests that immunological pressures might be starting to influence the evolution of the SARS virus in human populations.”
(Ruan Y, et al. Lacet online 2003 May 9)

Below is the commentary on the above Ruan’s article.
Comparative analysis of the SARS coronavirus genome: a good start to a long journey
(Brown EG and Tetro A, Lancet online 2003, May 9 http://image.thelancet.com/extras/03cmt124web.pdf )

Clinical progression and viral load in a community outbreak of coronavirus–associated SARS pneumonia: a prospective study
(http://image.thelancet.com/extras/03art4432web.pdf )

Background: We investigated the temporal progression of the clinical, radiological, and virological changes in a community outbreak of severe acute respiratory syndrome (SARS).

Methods: We followed up 75 patients for 3 weeks managed with a standard treatment protocol of ribavirin and corticosteroids, and assessed the pattern of clinical disease, viral load, risk factors for poor clinical outcome, and the usefulness of virological diagnostic methods.

Findings: Fever and pneumonia initially improved but 64 (85%) patients developed recurrent fever after a mean of 8•9 (SD 3•1) days, 55 (73%) had watery diarrhoea after 7•5 (2•3) days, 60 (80%) had radiological worsening after 7•4 (2•2) days, and respiratory symptoms worsened in 34 (45%) after 8•6 (3•0) days. In 34 (45%) patients, improvement of initial pulmonary lesions was associated with appearance of new radiological lesions at other sites. Nine (12%) patients developed spontaneous pneumomediastinum and 15 (20%) developed acute respiratory distress syndrome (ARDS) in week 3. Quantitative reverse–transcriptase (RT) PCR of nasopharyngeal aspirates in 14 patients (four with ARDS) showed peak viral load at day 10, and at day 15 a load lower than at admission. Age and chronic hepatitis B virus infection treated with lamivudine were independent significant risk factors for progression to ARDS (p=0•001). SARS–associated coronavirus in faeces was seen on RT–PCR in 65 (97%) of 67 patients at day 14. The mean time to seroconversion was 20 days.

Interpretation: The consistent clinical progression, shifting radiological infiltrates, and an inverted V viral–load profile suggest that worsening in week 2 is unrelated to uncontrolled viral replication but may be related to immunopathological damage.”
(Peiris JSM ,et al.Lancet online 2003 May 9)

Risk of prevalent HIV infection associated with incarceration among injecting
drug users in Bangkok, Thailand: case–control study

(http://bmj.com/cgi/content/full/326/7384/308 )

OBJECTIVES: To identify risks for HIV infection related to incarceration among injecting drug users in Bangkok, Thailand.

DESIGN: Case–control study of sexual and parenteral exposures occurring before, during, and after the most recent incarceration.

SETTING: Metropolitan Bangkok.

PARTICIPANTS: Non–prison based injecting drug users formerly incarcerated for at least six months in the previous five years, with documented HIV serostatus since their most recent release; 175 HIV positive cases and 172 HIV negative controls from methadone clinics.

MAIN OUTCOME MEASURE: Injection of heroin and methamphetamine, sharing needles, sexual behavior, and tattooing before, during, and after incarceration.

RESULTS: In the month before incarceration cases were more likely than controls to have injected methamphetamine and to have borrowed needles. More cases than controls reported using drugs (60% v 45%; P=0.005) and sharing needles (50% v 31%; P<0.01) in the holding cell before incarceration. Independent risk factors for prevalent HIV infection included injection of methamphetamine before detention (adjusted odds ratio 3.3, 95% confidence interval 1.01 to 10.7), sharing needles in the holding cell (1.9, 1.2 to 3.0), being tattooed while in prison (2.1, 1.3 to 3.4), and borrowing needles after release (2.5, 1.3 to 4.4).

CONCLUSIONS: Injecting drug users in Bangkok are at significantly increased risk of HIV infection through sharing needles with multiple partners while in holding cells before incarceration. The time spent in holding cells is an important opportunity to provide risk reduction counseling and intervention to reduce the incidence of HIV.”
(Buavirat A, et al. BMJ 2003 Feb 8;326(7384):308)


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